Nokea
The MOST common cause of sleeping difficulty in the first 2 months of life is
- A. gastro-esophageal reflux
- B. colic
- C. formula intolerance
- D. developmentally self-resolving sleeping behavior
Correct Answer: B
Rationale: Colic is a frequent cause of sleep difficulties in young infants.
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Which statement best describes the clinical manifestations of the preterm newborn?
- A. Head is proportionately small in relation to the body.
- B. Sucking reflex is absent, weak, or ineffectual.
- C. Thermostability is well established.
- D. Extremities remain in attitude of flexion.
Correct Answer: D
Rationale: The statement that best describes the clinical manifestations of the preterm newborn is that the extremities remain in an attitude of flexion. This characteristic is known as the "fetal position" and is commonly observed in preterm infants due to their premature musculoskeletal development. The flexed position of the extremities is a result of the baby's position in the uterus and is a normal finding for preterm newborns. Other clinical manifestations of preterm newborns may include a disproportionately large head in relation to the body, an immature or weak sucking reflex, and decreased thermostability due to their underdeveloped thermoregulatory systems.
A healthy 4-year-old child has a left flank mass. Computerized tomography (CT) scan of the abdomen shows a localized renal mass. Radical nephrectomy is performed; the histology shows clear cell sarcoma of the kidney. The MOST appropriate next step in the management is
- A. CT scan of the chest
- B. CT scan of the brain
- C. bone scan
- D. magnetic resonance imaging (MRI) of the brain
Correct Answer: C
Rationale: Clear cell sarcoma of the kidney has a propensity to metastasize to bones, making a bone scan essential.
The nursing care for the client in addisonian crisis should include which of the following interventions?
- A. Encouraging independence with activities of daily living (ADL)
- B. Allowing ambulation as tolerated
- C. Offering extra blankets and raising the heat in the room to keep the client warm
- D. Placing the client in a private room
Correct Answer: C
Rationale: The nursing care for a client in Addisonian crisis, also known as adrenal crisis, should include offering extra blankets and raising the heat in the room to keep the client warm. Addisonian crisis is a life-threatening condition that occurs when the body does not have enough cortisol and aldosterone, which are hormones produced by the adrenal glands. Symptoms of Addisonian crisis include severe weakness, fatigue, abdominal pain, nausea, vomiting, and low blood pressure. By offering extra blankets and raising the room temperature, the nurse can help prevent hypothermia, which can worsen the client's condition. It is important to maintain the client's body temperature to promote comfort and prevent further complications during Addisonian crisis.
The nurse has been asked to prepare an intervention plan for a client, age 70, admitted for treatment of renal calculi. He complains of frequent pain due to increased pressure in the renal pelvis and is frightened of the excruciating pain. Which of the ff measures can the nurse include in the client's nursing care plan? Choose all that apply
- A. Administer prescribed nephrotoxic drugs
- B. Encourage ambulation and liberal fluid
- C. Observe aseptic principles when changing intake
- D. Provide a comfortable position
Correct Answer: B
Rationale: A. Administer prescribed nephrotoxic drugs - This measure is not appropriate for the client's care plan as nephrotoxic drugs can further harm the kidneys, exacerbating the condition of renal calculi.
Arthur, a 66-year old client for pneumonia has a temperature ranging from 39° to 40° C with periods of diaphoresis. Which of the following interventions by Nurse Carlos would be a priority?
- A. Administer oxygen therapy
- B. provide frequent linen changes
- C. provide fluid intake 3L/day
- D. maintain complete bed rest
Correct Answer: A
Rationale: Administering oxygen therapy would be the priority intervention in this case because Arthur is experiencing pneumonia with a high fever (39° to 40° C). High fever can lead to increased oxygen demand in the body, and providing supplemental oxygen can help ensure that Arthur is receiving adequate oxygenation to support his respiratory function. Oxygen therapy can also help improve oxygen saturation levels, which may be compromised due to the pneumonia. Therefore, addressing the potential respiratory distress caused by the pneumonia and fever should be the top priority to optimize Arthur's oxygenation levels and respiratory function.